Deb Haley, Medicare Insurance Broker

Answer: Good news! The coverage gap stage of prescription coverage, also known as the donut hole, was eliminated in 2025. There is now a $2,000 annual maximum out of pocket for your drug copays, after which you pay $0 copay for your medications for the remainder of the calendar year.

Answer: The drug formulary for each of the carriers is typically the same whether the medications are bundled in on their Medicare Advantage plan offering or on a standalone part D plan that they offer. The difference in price is that with the Medicare Advantage plan the prescription coverage is bundled in and there is no additional premium. The standalone Part D plans have a monthly premium that you pay in addition to your annual drug deductible s and copays. It would make sense to look at both options to see if there is a significant difference in price either way. The choice to go on a separate Part D plan may also be influenced by whether or not all of your medical providers are in network for a particular Medicare Advantage plan.

Answer: Medicare typically doesn't cover experimental treatments, however it may cover certain testing required while the experimental treatment is going on but that would likely need prior authorization.

Answer: Creditable coverage is health insurance and prescription drug coverage that is as good or better than what is offered through original Medicare. If you have creditable coverage through an employer plan then you can delay in rolling in Medicare and avoid the late enrollment penalties.

Answer: Starting in January of 2025 there is no longer a coverage gap (donut hole) which was formerly stage 3 Medicare prescription pricing. Instead it has been replaced by a $2,000 per year maximum copay amount. Once you have reached that maximum your co-pays will be $0 for your medications listed on your plans formulary for the remainder of that calendar year.

Answer: You should plan to look at all available plans in your area and find a broker who is licensed with several products so they can help you compare your options and costs. Check with your friends, relatives, neighbors, or coworkers for a referral to an agent that they worked with that did well by them. You may also check with your local senior center as many agents advertise or offer educational seminars there.

Answer: You may switch to a lower cost supplement plan offered in your area. An example of this might be switching from a supplement G to a supplement N. You may explore discounts available such as same household discounts. Or you may want to consider moving from a supplement plan to a Medicare Advantage plan with lower upfront costs.

Answer: Late enrollment penalties only apply if you do not enroll in Medicare parts A and B within 3 months after you turn 65 or within 63 days of your employer health coverage ending if you continue to work and are covered by the employer for health insurance after the age of 65.

Answer: Yes, absolutely there should be stricter guidelines and rules that agents must follow when marketing and enrolling Medicare beneficiaries in Part C plans. And the private carriers of the Medicare Advantage plans should be overseeing their brokers who are contracted with them to ensure that they are following all the rules that apply.

Answer: Most items that are covered under durable medical equipment by Medicare Will have a 20% copay to the member. Certain items such as a wheelchair with customizations may require a doctor's prescription and others, for example a shower chair, would not require a prescription. If you are enrolled in a Medicare Advantage plan you will want to check with the plan to ensure that you are using an in-network supplier to keep your cost at the lowest possible rate. And oftentimes places like senior centers will have received donations for things like transport chairs, walkers, shower chairs that you can borrow.

Answer: In Massachusetts if your income drops below $2,824 a month for an individual for $3,833 for a married couple you can apply for a Medicare savings program that will pay your Medicare Part B premium and potentially some of your copays.

Answer: There is a special enrollment. When you move out of your residential area in which you have 60 days to re-enroll in a new plan.

Answer: Most Medicare plans cover cataract surgery, however the lens you can choose must be either for distance or near. If you choose to have the upgraded lens that covers both you will have an additional charge. If you use a standard lens and need new prescription eyewear after the surgery there typically is no cost for the eyewear.

Answer: Medicare Savings Programs help eligible medicare beneficiaries with the cost of their Part B premium. In Massachusetts the program is called Mass Buy-In and the depending on which level of the program someone qualifies for there may be additional help with things like copays.

Answer: One Medicare rule that is outdated and unfair is when someone is first eligible for Medicare and are allowed to enroll in just part A and they continue to work and contribute to an HSA account, once they enroll in Part A they are no longer allowed to contribute pre-tax dollars to their HSA account. They may also be subject to a penalty if they did not stop contributing to the HSA account 6 months prior to retirement. This is outdated and unfair to seniors who continue to work because most people these days do not plan their retirement 6 months in advance.